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HomeMy WebLinkAbout2024-00066720 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 DIII III (III (IIIIII II 11111111111111111011III 11111 III I I DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003593:52- u, 1 U21 1 1 1 U11 O U2 1 U, 1 U2 1 U1 1 U2 1 4 9 U1 1 u221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 El NOT ON S VEHICLE/PROPERTY inOVER$1.500 El AMENDEDCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash YR 2024I2024-00066720 VENT * ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '11 COOKANE AVE ®gin El ❑Y coN l O 18 2024 11:43 ❑AM ❑YES ®No u1 .•< PRIVATE mo /day I yr ®PM FLOW CONDITION m 'COUNTY PROPERTY ❑Y ®N DOORING ❑y #OF MOTOR ❑SLOW 1 U) El /MI N E S W Cook HIT&RUN ❑Y ® N WITH N VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF ) PEDALCYCUST® ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEE ❑PEDAL ❑EOUES ❑NIA/ ❑Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 0 0 9 / 1 4 J 2 0 0 4 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) .GONZALO.A. mo day yr Nissan Altima 2013 00-NONE 11 . 12 D1 DUE TO CRASH El 13-UNDERCARRIAGE ip FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 1l U2 m 1649 MCKOOL AVE M ❑Y ®SYSNEM❑UNK VEH. O ATCRASH D 0 99-UUTHER NKNOWN 916-TOP�3 Distraction Value ALGN = r CITY PLATE NO. STATE YEAR POINT OF 8 •{I 6 ii 4 COM VEH 0 ® 1 0 m FIRST CONTACT 1 7__. 5 ^Yves,See Sidebar U1 0 Z 1 N4AL3AP7DN528836 NIA ❑Y ❑N U2 m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Y Same N/A 1 o HOSPITAL(TAKEN TO) INCIDENT • IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r '' RESPONDER Same VEHU L ❑Y ®N 2 0 m 0 DRIVER ® PARKED 0 DRIVERLESS ❑ PEE ❑PEDAL ❑EDUCE 0 RUM ❑NCv 0 ov DATE OF BIRTH CIRCLE NUMBER(S) Ut MAKE MODEL YEAR m m / / FOR DAMAGEDAREA(S) FRONT TOWED Y N s Toyota Camry 2016 00-NONE t i DUE TO CRASH ❑ ® 1 n NAME(LAST,FIRST,M) mo day yr 13-UNDER CARRIAGE of 12 I:_2 FIRE ❑ ® U2 C v STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED A': SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 IN SPDR 0 ❑Y (2/ N 'DUNK VEH. AT CRASH 99-UNKNOWN •Distraction Value Ut 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ©I , 4 COM VEH ❑ to 1— FIRST CONTACT 7 Q-J 6 i - ®5 •&Yes,See Sidebar Q503246 IL 2024 0 91 M TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 4T4BF1 FK9GR577166 PROGRESSIVE ❑y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Meanly-Vanessa.J. 981009731 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE.ZIP PHONE NUMBER 160 < RESPONDER POO NR 541 COOKANE AVE. E LG I N . IL,60120 (630)776-0526 U1 = (UNIT) I SEAT) (DOB' (SEX) ISAFT) (AIR) IINJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME'/(ADDRESS)7(TELEPHONE' (EMS) (HOSPITAL) 1 3 01 /1 9/2002 F 2 3 0 1 0 Margarita J. Carlos Tabares/2071 NARCISSUS AVE 2E.Hanover Park.IL,60133 U2 996 r (630)666-8961 / / #OCCS D • / / ut2 m Ito I I 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 18 1 10/19 /2024 11 43 ®pm in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM It YES check one below: U1 1 0 T 2 0 19 28 ! I ❑PM ❑Construction * t N 3 0 ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 El AM ❑Maintenance U2 •Q ® 11 1 ARREST NAME TBOADA,GONZALO.A. 11-601 751628 / / PM o U ®CITATIONS ISSUED PENDINGTIME 0 Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM 25 2 0 ARREST NAME TBOADA-GONZALO,A. 11-708 751627 107 19 /2024 00 43 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 El A" Workers present? ❑Y 24 1535-Solis. Laura 401 - 11 ,26/2024 10 30 p PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. _ 0 IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; _� } A CMV is defined as any motor vehicle used to transport passengers or property and. D 1 Has a weight rating more than 10,000 pounds(example truck or truck/trailer r } I I i combination) or —I INDICATE NORTH XI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I ', i m -t ` r r r (example'.shuttle or charter bus)-or C) X o- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 <____a____. , , co Not lb SC819 1 -. . } } } transporting employees in the course of their employment(example employee M r. transporter-usually a van type vehicle or passenger car).or w �_ A____: : , U } : i i 4 Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example.large van used for specific purpose).or O L____�____� ; , ! ; i } 1 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 0 J ` CARRIER NAME Z ' t ADDRESS 0 — — — N Mey?St I O CITY/STATE/ZIP r , MOTOR CARR ID ❑ Interstate ❑ Intrastate 0 Not in Comm./Govt. El Not in Comm./Other r , USDOT NO. ILCC NO. , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No M 7) m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown M Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 7a IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96'1 97-102'1 >10:' m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 ft Z Gray White u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑Lr DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED X DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO. DUE TO ❑ Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE